Provider Demographics
NPI:1477677003
Name:KUPKA-MOORE, SUSANNE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:M
Last Name:KUPKA-MOORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SUSANNE
Other - Middle Name:M
Other - Last Name:KUPKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:34 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-1017
Mailing Address - Country:US
Mailing Address - Phone:585-786-3676
Mailing Address - Fax:585-786-3896
Practice Address - Street 1:34 DUNCAN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1017
Practice Address - Country:US
Practice Address - Phone:585-786-3676
Practice Address - Fax:585-786-3896
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046184-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02172916Medicaid
NY161350913OtherFEDERAL TAX ID